Gender Dysphoria Services and Treatment

Effective January 1, 2016, gender dysphoria services, including gender reassignment surgery (GRS), may be covered when medically necessary and if the individual meets all criteria.

A predetermination of benefits must be submitted to evaluate medical necessity or medical appropriateness of the proposed treatment. If there is a discrepancy between the Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

You Must Meet the Following Criteria Considered for GRS

The individual being considered for GRS surgery must meet all the following criteria. The individual must have:

Reached the age of at least 18 years; and

The capacity to make a fully informed decision and to consent for treatment; and

Been diagnosed with persistent, well-documented gender dysphoria; and

Lived continuously for at least 12 months in the gender role (real life experiences) that is consistent with the preferred gender, without periods of time returning the individual's original gender; and

Completed at least 12 months of continuous hormonal sex reassignment therapy of either male-to-female (MtF) or female-to-male (FtM); and

Undergone a urological examination to identify and treat abnormalities of the genitourinary tract; and

Been an active participant in a recognized gender identity treatment program; and

Referrals for surgery from the individual's qualified mental health professionals competent in the assessment and treatment of gender dysphoria, which include:

One referral required for breast/chest surgery that is mastectomy, chest reconstruction, or breast augmentation; and

Note regarding mental health services: If the first referral is from the individual's psychotherapist, the second referral should be from a clinician who has only had an evaluative role with the individual. Two separate letters, or one letter signed by both (if both are practicing within the same clinic or program), may be sent. Psychotherapy is not required for GRS except when the mental health professional's initial assessment recommends psychotherapy that specifies the goals of treatment and estimates its frequency and duration throughout the real life experience.

Male-to-Female (MtF) surgical procedures performed as part of gender reassignment services for an individual who has met the above criteria for gender dysphoria may be considered medically necessary and include the following:

Breast modification, including but not limited to breast enlargement, breast augmentation, mastopexy, implant insertion, and silicone injections, and nipple or areola reconstruction;

Clitoroplasty;

Coloproctostomy;

Colovaginoplasty;

Labioplasty;

Orchiectomy;

Penectomy;

Penile skin inversion;

Repair of introitus;

Vaginoplasty with construction of vagina with graft; and/or

Vulvoplasty.

Female-to-Male (FtM) surgical procedures performed as part of gender reassignment services for an individual who has met the above criteria for gender dysphoria may be considered medically necessary and include the following:

Procedures or services to create and maintain gender specific characteristics (masculinization or feminization) as part of the overall desired gender reassignment services treatment plan may be considered medically necessary for the treatment of gender dysphoria ONLY. These procedures may include the following:

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